|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$174.47
|
| Rate for Payer: Blue Shield of California Commercial |
$144.46
|
| Rate for Payer: Blue Shield of California EPN |
$136.55
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: Dignity Health Senior |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.00
|
| Rate for Payer: Heritage Provider Network Senior |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$174.47 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.49
|
| Rate for Payer: Heritage Provider Network Senior |
$157.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
OP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$197.74 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$174.47
|
| Rate for Payer: Blue Shield of California Commercial |
$144.46
|
| Rate for Payer: Blue Shield of California EPN |
$136.55
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.74
|
| Rate for Payer: Dignity Health Senior |
$197.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.00
|
| Rate for Payer: Heritage Provider Network Senior |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.74
|
| Rate for Payer: Vantage Medical Group Senior |
$197.74
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
IP
|
$232.63
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
ERX40831875
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$174.47 |
| Rate for Payer: Adventist Health Commercial |
$46.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.82
|
| Rate for Payer: Cash Price |
$104.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.49
|
| Rate for Payer: Heritage Provider Network Senior |
$157.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$174.47
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Blue Shield of California Commercial |
$10.21
|
| Rate for Payer: Blue Shield of California EPN |
$9.65
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Senior |
$13.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Senior |
$10.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
NDC40831876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.13
|
| Rate for Payer: Heritage Provider Network Senior |
$11.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
OP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.26 |
| Max. Negotiated Rate |
$165.61 |
| Rate for Payer: Adventist Health Commercial |
$38.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$104.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$133.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$165.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$107.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$146.12
|
| Rate for Payer: Blue Shield of California Commercial |
$120.99
|
| Rate for Payer: Blue Shield of California EPN |
$114.37
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$165.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$165.61
|
| Rate for Payer: Dignity Health Senior |
$165.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$124.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.60
|
| Rate for Payer: Heritage Provider Network Senior |
$120.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$93.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.71
|
| Rate for Payer: Multiplan Commercial |
$146.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$165.61
|
| Rate for Payer: Vantage Medical Group Senior |
$165.61
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
IP
|
$194.83
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
ERX197246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.26 |
| Max. Negotiated Rate |
$146.12 |
| Rate for Payer: Adventist Health Commercial |
$38.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$133.85
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.90
|
| Rate for Payer: Heritage Provider Network Senior |
$131.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.71
|
| Rate for Payer: Multiplan Commercial |
$146.12
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$584.48 |
| Rate for Payer: Adventist Health Commercial |
$155.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$535.38
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$527.59
|
| Rate for Payer: Heritage Provider Network Senior |
$527.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.82
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
ERX220449
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Adventist Health Commercial |
$155.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$416.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$535.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$584.48
|
| Rate for Payer: Blue Shield of California Commercial |
$483.95
|
| Rate for Payer: Blue Shield of California EPN |
$457.45
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$506.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$662.40
|
| Rate for Payer: Dignity Health Senior |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$498.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$482.39
|
| Rate for Payer: Heritage Provider Network Senior |
$482.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$375.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.82
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
IP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$584.48 |
| Rate for Payer: Adventist Health Commercial |
$155.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$535.38
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$527.59
|
| Rate for Payer: Heritage Provider Network Senior |
$527.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.82
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
OP
|
$779.30
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
ERX197247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Adventist Health Commercial |
$155.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$416.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$535.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$662.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$428.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$584.48
|
| Rate for Payer: Blue Shield of California Commercial |
$483.95
|
| Rate for Payer: Blue Shield of California EPN |
$457.45
|
| Rate for Payer: Cash Price |
$350.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$506.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$662.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$662.40
|
| Rate for Payer: Dignity Health Senior |
$662.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$498.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$482.39
|
| Rate for Payer: Heritage Provider Network Senior |
$482.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$375.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.82
|
| Rate for Payer: Multiplan Commercial |
$584.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$662.40
|
| Rate for Payer: Vantage Medical Group Senior |
$662.40
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
OP
|
$271,800.00
|
|
|
Service Code
|
NDC 68403-1100-6
|
| Hospital Charge Code |
NDG213747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49,195.80 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$145,277.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186,726.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$203,850.00
|
| Rate for Payer: Blue Shield of California Commercial |
$168,787.80
|
| Rate for Payer: Blue Shield of California EPN |
$159,546.60
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125,028.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$231,030.00
|
| Rate for Payer: Dignity Health Senior |
$231,030.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173,952.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$125,843.40
|
| Rate for Payer: Heritage Provider Network Senior |
$125,843.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131,007.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49,195.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67,950.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99,098.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90,808.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
IP
|
$271,800.00
|
|
|
Service Code
|
NDC 68403-1100-6
|
| Hospital Charge Code |
NDG213747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49,195.80 |
| Max. Negotiated Rate |
$203,850.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186,726.60
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125,028.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$146,772.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$184,008.60
|
| Rate for Payer: Heritage Provider Network Senior |
$184,008.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49,195.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67,950.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99,098.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90,808.38
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
IP
|
$3,387.63
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$3,387.63 |
| Max. Negotiated Rate |
$3,387.63 |
| Rate for Payer: IEHP Medi-Cal |
$3,387.63
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
IP
|
$4,448.19
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$4,448.19 |
| Max. Negotiated Rate |
$4,448.19 |
| Rate for Payer: IEHP Medi-Cal |
$4,448.19
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
IP
|
$11,902.94
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$11,902.94 |
| Max. Negotiated Rate |
$11,902.94 |
| Rate for Payer: IEHP Medi-Cal |
$11,902.94
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
IP
|
$7,471.67
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$7,471.67 |
| Max. Negotiated Rate |
$7,471.67 |
| Rate for Payer: IEHP Medi-Cal |
$7,471.67
|
|
|
Brachytherapy (Inpatient)
|
Facility
IP
|
$23,184.00
|
|
|
Service Code
|
ICD OJHT01Z
|
| Min. Negotiated Rate |
$23,184.00 |
| Max. Negotiated Rate |
$23,184.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$23,184.00
|
|
|
Brachytherapy (Inpatient)
|
Facility
IP
|
$23,184.00
|
|
|
Service Code
|
ICD OJHS01Z
|
| Min. Negotiated Rate |
$23,184.00 |
| Max. Negotiated Rate |
$23,184.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$23,184.00
|
|
|
Brachytherapy Seeds - #2074
|
Facility
IP
|
$8,040.00
|
|
|
Service Code
|
ICD 01HY31Z
|
| Min. Negotiated Rate |
$8,040.00 |
| Max. Negotiated Rate |
$8,040.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,040.00
|
|
|
Brachytherapy Seeds - #2074
|
Facility
IP
|
$23,184.00
|
|
|
Service Code
|
ICD 0YHM41Z
|
| Min. Negotiated Rate |
$8,040.00 |
| Max. Negotiated Rate |
$23,184.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$23,184.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,040.00
|
|
|
Brachytherapy Seeds - #2074
|
Facility
IP
|
$8,040.00
|
|
|
Service Code
|
ICD D718BB1
|
| Min. Negotiated Rate |
$8,040.00 |
| Max. Negotiated Rate |
$8,040.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,040.00
|
|
|
Brachytherapy Seeds - #2074
|
Facility
IP
|
$8,040.00
|
|
|
Service Code
|
ICD DB12B6Z
|
| Min. Negotiated Rate |
$8,040.00 |
| Max. Negotiated Rate |
$8,040.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,040.00
|
|
|
Brachytherapy Seeds - #2074
|
Facility
IP
|
$8,040.00
|
|
|
Service Code
|
ICD 09HE01Z
|
| Min. Negotiated Rate |
$8,040.00 |
| Max. Negotiated Rate |
$8,040.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,040.00
|
|
